RESUMO
Resumo Coarctação da aorta abdominal é uma causa rara de claudicação de membros inferiores e hipertensão refratária. O tratamento é complexo e exige conhecimento de diversas técnicas de reconstrução vascular. Apresentamos um caso de coarctação ao nível das artérias renais, seu tratamento e revisão da literatura. Paciente feminina, 65 anos, com hipertensão refratária desde os 35 anos, utilizando cinco medicações anti-hipertensivas em dose máxima. Pressão arterial média de 260/180mmHg e claudicação incapacitante (menos de 20 metros) bilateral. Angiotomografia computadorizada demonstrou coarctação de aorta justarrenal de 4 mm de maior diâmetro, calcificação circunferencial no local da estenose e tortuosidade da aorta infrarrenal. Foi submetida a tratamento híbrido, com ponte ilíaco-birrenal e implante de stent Advanta V12 no local da estenose. A paciente evoluiu satisfatoriamente e, 60 dias depois da cirurgia, apresentava-se com uma pressão arterial de 140/80mmHg, em uso de apenas duas medicações anti-hipertensivas e sem claudicação.
Abstract Coarctation of the abdominal aorta is a rare etiology of intermittent claudication and refractory hypertension. Treatment is complex and requires knowledge of several vascular reconstruction techniques. We report a case of aortic coarctation at the level of the renal arteries, describing its treatment and presenting a literature review. Female patient, 65 years old, with refractory hypertension since the age of 35, using five antihypertensive medications at maximum doses. Blood pressure was 260/180mmHg and she had disabling claudication (less than 20 meters). Computed tomography angiography showed a 4mm coarctation in the juxtarenal aorta, with circumferential calcification at the stenosis site, and tortuous infrarenal aorta. Hybrid repair was performed with an iliac-birenal bypass and implantation of an Advanta V12 stent at the stenosis site. The patient's postoperative course was satisfactory, she was free from claudication, and her blood pressure 60 days after surgery was 140/80mmHg, taking two antihypertensive medications.
Assuntos
Humanos , Feminino , Idoso , Coartação Aórtica/cirurgia , Coartação Aórtica/complicações , Aorta Abdominal , Coartação Aórtica/diagnóstico , Artéria Renal , Stents , Angioplastia com Balão , Hipertensão Renovascular/cirurgia , Hipertensão Renovascular/etiologia , Claudicação Intermitente/cirurgia , Claudicação Intermitente/etiologiaRESUMO
Renovascular hypertension (RVH) is defined as an elevated blood pressure caused by kidney hypoperfusion, generally as a result of anatomic stenosis of the renal artery with consequent activation of the Renin Angiotensin-Aldosterone System. The main causes include genetic and inflammatory disorders, extrinsic compression, and idiopathic alterations. RVH is often asymptomatic and should be suspected in any child with refractory hypertension, especially if other suggestive findings are present, including those with severe hypertension, abdominal bruit, and abrupt fall of glomerular filtration rate after administration of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers. There is a consensus that digital subtraction angiography is the gold standard method for the diagnosis of RVH. Nevertheless, the role of non-invasive imaging studies such as Doppler ultrasound, magnetic resonance angiography, or computed tomographic angiography remains controversial, especially due to limited pediatric evidence. The therapeutic approach should be individualized, and management options include non-surgical pharmacological therapy and revascularization with percutaneous transluminal renal angioplasty (PTRA) or surgery. The prognosis is related to the procedure performed, and PTRA has a higher restenosis rate compared to surgery, although a decreased risk of complications. This review summarizes the causes, physiopathology, diagnosis, treatment, and prognosis of RVH in pediatric patients. Further studies are required to define the best approach for RVH in children.
Assuntos
Hipertensão Renovascular , Obstrução da Artéria Renal , Angioplastia com Balão , Criança , Humanos , Hipertensão Renovascular/diagnóstico , Hipertensão Renovascular/etiologia , Hipertensão Renovascular/terapia , Artéria Renal/patologia , Obstrução da Artéria Renal/diagnóstico , Obstrução da Artéria Renal/diagnóstico por imagemRESUMO
30 to 40% of the adult population worldwide has been diagnosed with hypertension, among these patients 5 to 10% of them could have a possibly curable condition. In order to recognize this special population, the clinician must perform a complete work up and be aware of the main underlying causes of secondary hypertension. Often this could be a goal difficult to accomplish. The purpose of this article is to discuss the most frequent causes of secondary hypertension and offer a diagnostic approach for these patients. Clinicians should never forget that drug-related hypertension is a common cause that is discovered only with the help of a good medical history.
Assuntos
Humanos , Hipertensão/prevenção & controle , Hipertensão Renovascular/etiologia , Feocromocitoma , Síndromes da Apneia do Sono , Monitorização Ambulatorial da Pressão Arterial , Hiperaldosteronismo , Hipertensão/diagnóstico , Hipertensão/etiologia , Hipertensão Renovascular/diagnóstico , Anti-Hipertensivos/uso terapêuticoRESUMO
The rodent renovascular hypertension model has been used to investigate the mechanisms promoting hypertension. The importance of the carotid body for renovascular hypertension has been demonstrated. As the commissural NTS (cNTS) is the first synaptic site in the central nervous system that receives information from carotid body chemoreceptors, we evaluated the contribution of cNTS to renovascular hypertension in the present study. Normotensive male Holtzman rats were implanted with a silver clip around the left renal artery to induce two-kidney, one-clip (2K1C) hypertension. Six weeks later, isoguvacine (a GABAA agonist) or losartan (an AT1 antagonist) was injected into the cNTS, and the effects were compared with carotid body removal. Immunohistochemistry for Iba-1 and GFAP to label microglia and astrocytes, respectively, and RT-PCR for components of the renin-angiotensin system and cytokines in the NTS were also performed 6 weeks after renal surgery. The inhibition of cNTS with isoguvacine or the blockade of AT1 receptors with losartan in the cNTS decreased the blood pressure and heart rate of 2K1C rats even more than carotid body removal did. The mRNA expression of NOX2, TNF-α and IL-6, microglia, and astrocytes also increased in the cNTS of 2K1C rats compared to that of normotensive rats. These results indicate that tonically active neurons within the cNTS are essential for the maintenance of hypertension in 2K1C rats. In addition to signals from the carotid body, the present results suggest that angiotensin II directly activates the cNTS and may also induce microgliosis and astrogliosis within the NTS, which, in turn, cause oxidative stress and neuroinflammation.
Assuntos
Hipertensão Renovascular/etiologia , Núcleo Solitário/metabolismo , Bloqueadores do Receptor Tipo 1 de Angiotensina II , Animais , Corpo Carotídeo/cirurgia , Hipertensão Renovascular/patologia , Hipertensão Renovascular/cirurgia , Masculino , Ratos Sprague-Dawley , Núcleo Solitário/patologiaAssuntos
Hipertensão/etiologia , Aterosclerose/complicações , Brasil , Doenças do Sistema Endócrino/complicações , Medicina Baseada em Evidências , Displasia Fibromuscular/complicações , Humanos , Hiperaldosteronismo/complicações , Hipertensão/induzido quimicamente , Hipertensão/diagnóstico , Hipertensão Renovascular/diagnóstico , Hipertensão Renovascular/etiologia , Hipertensão Renovascular/terapia , Artéria Renal , Apneia Obstrutiva do Sono/complicaçõesRESUMO
Se presenta el caso clínico de una paciente que debutó con hipertensión arterial (HTA) grado II realizándose los estudios sistematizados correspondientes para descartar patologías secundarias. Dentro de los estudios de primera línea en la valoración merece destacarse la ecografía Doppler renal por la información que ella aporta, orientado al diagnóstico de estenosis de la arteria renal. La identificación de una HTA de origen renovascular supone el hallazgo de una de las causas reversibles de hipertensión. Dentro de esta etiología la más frecuente es la displasia fibromuscular (DFM) que mejora con la corrección de la estenosis mediante técnicas quirúrgicas o percutáneas con angioplastia con balón o stent. El objetivo es presentar un caso clínico para mostrar la complejidad del proceso diagnóstico y la importancia que tiene la sospecha clínica para la corrección oportuna de este tipo de HTA reversible...
Assuntos
Humanos , Adolescente , Feminino , Displasia Fibromuscular/complicações , Displasia Fibromuscular/diagnóstico , Displasia Fibromuscular/terapia , Hipertensão Renovascular/etiologia , Obstrução da Artéria Renal/terapia , Ecocardiografia Doppler , Exame FísicoRESUMO
Se presenta el caso clínico de una paciente que debutó con hipertensión arterial (HTA) grado II realizándose los estudios sistematizados correspondientes para descartar patologías secundarias. Dentro de los estudios de primera línea en la valoración merece destacarse la ecografía Doppler renal por la información que ella aporta, orientado al diagnóstico de estenosis de la arteria renal. La identificación de una HTA de origen renovascular supone el hallazgo de una de las causas reversibles de hipertensión. Dentro de esta etiología la más frecuente es la displasia fibromuscular (DFM) que mejora con la corrección de la estenosis mediante técnicas quirúrgicas o percutáneas con angioplastia con balón o stent. El objetivo es presentar un caso clínico para mostrar la complejidad del proceso diagnóstico y la importancia que tiene la sospecha clínica para la corrección oportuna de este tipo de HTA reversible.
Assuntos
Humanos , Feminino , Adolescente , Hipertensão Renovascular/etiologia , Obstrução da Artéria Renal/terapia , Displasia Fibromuscular/complicações , Displasia Fibromuscular/diagnóstico , Displasia Fibromuscular/terapia , Exame Físico , Ecocardiografia DopplerAssuntos
Humanos , Adulto , Pessoa de Meia-Idade , Arterite/complicações , Aterosclerose/complicações , Hipertensão Renovascular/etiologia , Hipertensão Renovascular/fisiopatologia , Hipertensão Renovascular/reabilitação , Rim , Rim , Angioplastia/reabilitação , Artéria Renal , Captopril/administração & dosagem , Fatores de Risco , Tomografia , Ultrassonografia DopplerRESUMO
Takayasu's arteritis is a chronic and non-specific disease of young women in reproductive age that primarily affects the aorta, its branches and the pulmonary artery. Ramirez Cueto G. and Fernandez Del Castillo C. et al. published a case of pregnancy in Mexico and Takayasu's arteritis in 1968. There are no reports of this disease in pregnancy since. The purpose of this study is to describe the clinical course and perinatal outcome of seven pregnant patients with known diagnosis of Takayasu arteritis. The clinical course, laboratory findings, angiographic findings and perinatal outcomes were assessed in retrospect in seven pregnant patients with diagnosis of Takayasu's arteritis seen at the National Institute of Perinatology Isidro Espinosa Reyes (Mexico) during the period 2002-2010. The results of the conducted follow-up of 7 patients pregnant with Takayasu's arteritis were: 3 patients were complicated with pre-eclampsia and 2 newborn presented intrauterine growth restriction. Disease activity wasn't observed during pregnancy. No cases of congestive heart failure, brain ischemia or maternal deaths were presented. There were no fetal deaths. We didn't observed induced activity during pregnancy in the cases presented. The most common mother complication was type renovascular hypertension with added severe preeclampsia, which determined the presence of intrauterine growth restriction. There were no maternal or perinatal deaths.